孕激素与早产.pptVIP

孕激素与早产的预防 南京军区总院妇产科 杨林东 1934年孕激素被分离出来，1954年报道了其使子宫平滑肌处于寂静状态的作用 2003-2011年，出现了17-a羟己酸孕酮或天然口服孕激素或经阴道使用孕激素预防早产效果评价文章 2011年2月，美国FDA批准了17-a羟己酸孕酮(17P)注射剂Makena用于减少早产风险 2012年5月，美国母婴医学协会出版了相应的临床指南 MECHANISMS An antiinflammatory effect that counteracts the inflammatory process leading to PTB (preterm birth) A local increase in progesterone in gestational tissues that counteracts the functional decrease in progesterone leading to PTB MECHANISMS Stimulate transcription of ZEB1 and ZEB2, which inhibit connexin 43 (gap-junction protein that helps synchronize contractile activity) and oxytocin-receptor gene Decrease prostaglandin synthesis, infection-mediated cytokine production (antiin?ammatory effects) by fetal membranes/placenta Changes in PR-A and PR-B expression (decreased PR-A/PR-B ratio keeps uterus quiescent) Membrane-bound PR in myometrium PRs, when stimulated by progesterone, help selected gene promotion, or prevent binding of other factors …… The evidence with no prior PTB and unknown CL (Levels I and III) 17P In 168 women, 17P 1000 mg IM weekly starting at 16-20 weeks was not associated with any effect on the incidence of PTB or perinatal outcomes compared to placebo. Vaginal progesterone No RCT has evaluated the effect of vaginal progesterone in this population. In summary There is insuf?cient evidence to determine the impact on PTB of progestogens in singleton gestations with no history of PTB, and with unknown or normal CL. The evidence with no prior PTB, but short CL (Levels I, II, and III) Vaginal progesterone In 458 women with TVU CL 10-20 mm at 19-23 6/7 weeks, vaginal progesterone 90-mg gel daily started at 20-23 6/7 weeks until 36 6/7 weeks was associated with a 45% signi?cant reduction in PTB ＜ 33 weeks and a 43% signi?cant reduction in composite neonatal morbidity and mortality . In a metaanalysis, including 554 women, with TVU CL ＜ 25 mm mostly ＜ 25 weeks, vaginal proges